Diverticulitis
Occurs  in 10 to 25% of people with diverticulosis.
Perforation of  diverticulum.
LLQ pain, +/- fever, leukocytosis, and a palpable mass.
Differential diagnosis includes malignancy, ischemic colitis, infectious colitis, and inflammatory bowel disease

Uncomplicated Diverticulitis
50 to 70% will have no further episodes.
Increased risk of complications with recurrent disease.
Because colon carcinoma may have an identical clinical presentation to diverticulitis all patients must be evaluated for malignancy after resolution of the acute episode.

Complicated Diverticulitis
Complicated diverticulitis includes diverticulitis with:
abscess
obstruction
diffuse peritonitis (free perforation)
or fistulas between the colon and adjacent structures.
Colovesical, colovaginal, and coloenteric fistulas
Hinchey staging system

Classification of Diverticulitis
Hinchey Stage(11)
Stage I: Pericolic or mesenteric abscess Stage II: Walled-off pelvic abscess Stage III: Generalized purulent peritonitis Stage IV: Generalized fecal peritonitis

TRACHEOSTOMY_COMPLETE GUIDE

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Tracheostomy is one of the oldest surgical procedures.
A tracheotomy was portrayed on Egyptian tablets dated back to 3600 BC.
Asclepiades of Persia is credited as the first person to perform a tracheotomy in 100 BC.
The first successful tracheostomy was performed by Brasovala in the 15th century.

Tracheostomy History and indications
1932 prevent pulmonary infection in neurologically impair patients secondary to infections (poliomyelitis).
1943 remove bronchial secretions in cases of myasthenia gravis and tetanus.
1951 reduce the volume of dead space, use in COPD and severe penumonia.
1950 positive pressure through tracheostomy for patients with poliomyelitis.
1955 obstruction secondary to infection: diphteria, Ludwig’s angina.
1961 Obstructions secondary to tumour, infectious disease and trauma.

The Lindholm Scale of Laryngotracheal Damage
Grade I erythema and edema without ulceration Grade II superficial ulceration of the mucosa <1/3 airway circumference Grade III continuous deep ulceration <1/3 airway circumference or superficial ulceration >1/3 airway circumference Grade IV deep ulceration with exposed cartilage.

TRACHEOSTOMY VS TRANSLARYNGEAL INTUBATION
Increased patient mobility
More secure airway
Increased comfort
Improved airway suctioning
Early transfer of ventilator-dependent patients from the intensive care unit (ICU)
Less direct endolaryngeal injury
Enhanced oral nutrition
Enhanced phonation and communication
Decreased airway resistance for promoting weaning from mechanical ventilation
Decreased risk for nosocomial pneumonia in patient subgroups

TRACHEOSTOMY TUBE CARE
Securing tracheostomy around patient’s neck.

Tube changes:
Indications: soiled, cuff rupture.
Complications: insertion into a false passage bleeding, and patient discomfort.
Avoid within 1st week.
First tube change by surgeon.
Difficult cases (obese, short and thick neck), be prepared for endotracheal intubation.

Tracheostomy tube cuff pressures in a range of 20 to 25 mm Hg.
Overly low cuff pressures < 18 mm Hg, may cause the cuff to develop longitudinal folds, promote microaspiration of secretions collected above the cuff, and increase the risk for nosocomial pneumonia.
Excessively high cuff pressures above 25 to 35 mm Hg exceed capillary perfusion pressure and can result in compression of mucosal capillaries, which promotes mucosal ischemia and tracheal stenosis.
Cuff pressure should be measured with calibrated devices and recorded at least once every nursing shift and after every manipulation of the tracheostomy tube.

Chest Xray:
Cuff has a width greater than the caliber of the trachea, which suggests the presence of a hyperinflated cuff and tracheal overdistention

Humidification of the inspired gas is a standard of care for tracheostomized patients...

Grade of ureteral injuries
Grade I (haematoma) -Contusion or Haematoma.
Grade II (laceration) -Less than 50% transection.
Grade III (laceration) -Greater than 50% transection.
Grade IV (laceration) -Complete transection with 2 cm of devascularization.
Grade V (laceration) -Avulsion with greater than 2 cm of devascularization.

Type of Ureteral injuries
Crushing by misapplication of the clamps
Ligation with a suture
Transection ( Partial / complete)
Angulation of the ureter with secondary clips.
Ischaemia from ureteral stripping electro-coagulation.
Resection of a segment of ureter.
Combination of the above.

Incidence of surgical injury
Gynecologic surgery 50 – 66 %
General / Colorectal Surgery 15 – 25 %
Abdominal vascular surgery 5 – 10 %
Ureteroscopy (perforation) 1% - 5 %

Sites of ureteral injuries
usually involves the lower third
Ovarian vascular pedicle at infundibulo-pelvic ligament
Ureteric relation with the uterine artery.
Cardinal ligament, where the ureter crosses under the uterine artery.
Cardinal ligament tunnel, dorsal to the infundibulo -pelvic ligament near or at the pelvic brim.
Vaginal fornices.
Lateral rectal pedicles.
Pathological distortion of the ureteral anatomy.

Mode of presentation
Can present post operatively as
- Stricture
- Urinoma
- Fistula
- Obstructive uropathy

Aortic Arch Anomalies

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The aortic arches are a series of six paired embryological vascular structures which give rise to several major arteries. The first and second arches disappear early, but the dorsal end of the second gives origin to the stapedial artery, a vessel which atrophies in humans but persists in some mammals. The third aortic arch constitutes the commencement of the internal carotid artery, and is therefore named the carotid arch.The fourth right arch forms the right subclavian as far as the origin of its internal mammary branch; while the fourth left arch constitutes the arch of the aorta between the origin of the left carotid artery and the termination of the ductus arteriosus.The fifth arch disappears on both sides.The proximal part of the sixth right arch persists as the proximal part of the right pulmonary artery while the distal section degenerates; The sixth left arch gives off the left pulmonary artery and forms the ductus arteriosus; this duct remains pervious during the whole of fetal life, but then closes within the first few days after birth due to increased O2 concentration.

Most defects of the grest arteries arise as a result of persistence of aortic arches that normally should regress or regression of arches that normally shouldn't.
    Aberrant subclavian artery; with regression of the right aortic arch 4 and the right dorsal aorta, the right subclavian artery has an abnormal origin on the left side, just below the left subclavian artery. To supply blood to the right arm, this forces the right subclavian artery to cross the midline behind the trachea and esophagus, which may constrict these organs, although usually with no clinical symptoms.
    A double aortic arch; occurs with the development of an abnormal right aortic arch in addition to the left aortic arch, forming a vascular ring around the trachea and esophagus, which usually causes dificutly breathing and swallowing. Occasionally, the entire right dorsal aorta abnormally persists and the left dorsal aorta regresses in which case the right aorta will have to arch across from the esophagus causing difficulty breathing or swallowing.
    Patent ductus arteriosus
    Coarctation of the aorta

SCARLET FEVER

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Scarlet fever is a disease caused by an infection with group A beta-hemolytic streptococcal bacteria. The rash initially appears on the neck and chest, then spreads over the body. While the rash is still red, the patient may develop Pastia's lines, bright red coloration of the creases under the arm and in the groin.

Scarlet fever (scarlatina) is an exotoxin-mediated disease arising from group A beta-hemolytic streptococcal infection. Ordinarily, scarlet fever evolves from a tonsillar/pharyngeal focus, although the rash develops in fewer than 10% of cases of "strep throat."  
Exotoxin-mediated streptococcal infections range from localized skin disorders (eg, bullous impetigo) to the systemic rash of scarlet fever to the uncommon but highly lethal streptococcal toxic shock syndrome.

Streptococci are gram-positive cocci that grow in chains. They are classified by their ability to produce a zone of hemolysis on blood agar and by differences in carbohydrate cell wall components.
Streptococci may be alpha-hemolytic (partial hemolysis), beta-hemolytic (complete hemolysis), or gamma-hemolytic (no hemolysis). Most streptococci excrete hemolyzing enzymes and toxins. Erythrogenic toxins cause the rash of scarlet fever. The erythema-producing toxin was discovered by Dick and Dick in 1924.
Group A streptococci are normal inhabitants of the nasopharynx. Group A streptococci can cause pharyngitis, skin infections, pneumonia, bacteremia, and lymphadenitis. Scarlet fever usually is associated with pharyngitis but, in rare cases, follows streptococcal infections at other sites.
Infections occur year-round, but the incidence of pharyngeal disease is highest in school-aged children (5-15 y) during winter and spring and in a setting of crowding and close contact. Person-to-person spread by respiratory droplets is the most common vector.
The incubation period for scarlet fever ranges from 12 hours to 7 days. Patients are contagious during the acute illness and during the subclinical phase.

In the US: Up to 10% of the population contracts group A streptococcal pharyngitis.
In the past century, the number of cases of scarlet fever has remained high, with marked decrease in case mortality rates secondary to widespread use of antibiotics.

The exanthem is diffusely erythematous; but, in some patients, it is more palpable than visible.
Exanthem usually has the texture of coarse sandpaper, and the erythema blanches with pressure.
The skin can be pruritic but usually is not painful.
A few days following generalization of the rash, it becomes more intense along skin folds and produces lines of confluent petechiae known as the Pastia sign. These lines are caused by increased capillary fragility.
The rash begins to fade 3-4 days after onset, and the desquamation phase begins. This phase begins with flakes peeling from the face. Peeling from the palms and around the fingers occurs about a week later and lasts for about a month after onset of the disease.

The appearance of the tongue also has a characteristic course in scarlet fever.
During the first 2 days of the disease, the tongue has a white coat through which the red and edematous papillae project. This is referred to as a white strawberry tongue.
After 2 days, the tongue also desquamates, resulting in a red tongue with prominent papillae called the red strawberry tongue..

Undergo various procedures and surgeries more commonly than their nondiabetic counterparts
Have increased morbidity and mortality rates when acutely compromised or ill
At least a third of perioperative diabetics are unrecognized or untreated before surgery
the physician must be vigilant in the identification of diabetes

Cardiac Consequences
Cardiac compromise must be identified before major surgery and during critical illness
High prevalence of silent ischemia warrants cardiac testing preoperatively
Acute glycemic control results in marked improvement in cardiac survival in diabetics with ACS, MI, and after recent cardiac surgery

Renal Consequences
Diabetes is the leading cause of end-stage renal disease
Leads to hypertension, dyslipidemias, and anemia
Developing acute renal failure after CABG increases mortality rate from 1-2% to 20% with moderate acute renal failure and 60% for patients who require dialysis

Goals of Critical Care
To avoid acute renal failure, leading to dialysis
Limiting hypovolemia
Avoiding nephrotoxins
Judicious use of contrast-based radiographic procedures
To decrease significant risk of aspiration (from autonomic neuropathy, gastroparesis)
Appropriate patient positioning
Use of gastric acid secretion suppressants

Glycemic Control
Multiple recent studies suggest that aggressive glucose control may benefit diabetic pts who are critically ill
Insulin infusions are recommended as a way of glycemic control

Glycemic Control of Diabetic Patient in ICU
CONCLUSION: The use of intensive insulin therapy to maintain blood glucose at a level that did not exceed 110 mg/dl substantially reduced mortality in the ICU and morbidity among critically ill patients admitted to ICU

Continuous Intravenous Insulin Infusion Reduces the Incidence of Deep Sternal Wound Infection in Diabetic patients After Cardiac Surgical Procedures

Hyperglycemia as a Risk Factor for Wound Infections
Hyperglycemia impedes the normal physiologic responses to infections
Periods of hyperglycemia are associated with accelerated nonenzymatic glycosylation of body proteins
C3 component of complement is inactivated and unable to bind to the surface of invading bacteria
Glycosylation of newly synthesized collagen in hyperglycemic animals is associated with increased collagenase activity and decreased wound collagen content
Impaired phagocytosis, delayed chemotaxis, and depressed bacteriocidal capacity
The degree of hyperglycemia that has been shown to impair phagocytic function is as low as 200 mg/dl
Wound healing impairment improves dramatically with control of glucose concentrations

Preoperative Cardiac Evaluation

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Perioperative Cardiac Outcomes
Ischemic Events
Congestive Heart Failure
Ventricular Tachycardia

Ischemic Events
Cardiac Death
Non-Fatal MI
Unstable Angina
 Chest pain >30 mins unresponsive to standard interventions
 Transient ST+T wave changes w/o Q waves
 No enzyme elevations
 Greater than or equal to 0.1mV ST depression during exercise

Major Clinical Predictors
If the patient has any of the major clinical predictors then the problem has to be addressed before surgery
Unstable coronary syndrome
decompensated CHF
significant arrhythmia
and severe valvular disease (aortic stenosis!)

Intermediate Predictors
Intermediate clinical predictors - Mild angina, prior MI, compensated or prior CHF, diabetes mellitus, and renal insufficiency
Assess functional status.  If <4 METs, consider non-invasive testing.  If >4METs and intermediate or low risk surgery, proceed to the OR

Minor Predictors
Advanced age, abnormal findings on echocardiography, rhythm other than sinus, history of stroke, low functional capacity, and uncontrolled hypertension
<4 METs and high-risk surgery, consider non-invasive testing

If <4 METs and intermediate or low-risk surgery proceed to OR
If >4 METs proceed to the OR

Interventions
Pharmacological vs. coronary revascularization
Recently, the Coronary Artery Revascularization Prophylaxis trial demonstrated that in the short term, there is no reduction in the number of postoperative myocardial infarctions, deaths, or duration of stay in the hospital, or in long-term outcomes in patients who underwent preoperative coronary revascularization compared with patients who received optimized medical therapy.

Pheochromocytoma

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A tumor of chromaffin cells that secrete catecholamines (epinephrine or norepinephrine) 
Typically benign, it is a well-encapsulated, lobular, vascular tumor that can weigh between 70-3600 g
Location is in the adrenal medulla in 80% of cases
They may also be found in extra-adrenal tissues derived from neural crest cells (called paraganglionomas)

Pathophysiology: medullary function 
Adrenal medulla: 80% epinephrine, 20% norepinephrine
Hormones stored in secretory cell granules
Release of hormones by preganglionic neurons

Catecholamine synthesis
Tyrosine hydroxylation
Decarboxylation of DOPA to dopamine
Hydroxylation to norepinephrine
Methylation of NE to epinephrine via PMNT

Epidemiology 
Rare neoplasm
Rare cause of secondary hypertension (<0.2% all causes HTN)
Seldom diagnosed (10% discovered incidentally)
A retrospective study from the Mayo Clinic- in 50% of cases, the diagnosis was made at autopsy (Beard, 1983).
Series by Fogerty, et. al., only 1 out of 300 patients evaluated for suspected pheochromocytoma were confirmed to carry the diagnosis.

Classic Association with MEN-2
 MEN-2A (Sipple’s Syndrome)
    Autosomal dominant
    MTC, pheochromocytoma, parathyroid hyperplasia
 MEN-2B
    Autosomal dominant
    MTC, pheochromocytoma, ganglioneuromas, prototypical facies
50% patients manifest symptoms of pheochromocytome
33% demonstrate HTN

Familial Association- higher incidence of pheochromocytoma
 VonHippel-Lindau Disease
 Von Recklinghausen’s Disease
 Sturge-Weber Syndrome
 Tuberous Sclerosis

Detection of congenital anomalies
The urology system is easily demonstrated sonographicaly even in utero.
The prenatal ultrasound era changed the approach and improved the outcome of various congenital urological anomalies.

Congenital anomalies diagnosed in adulthood
Not all pregnant women undergo prenatal US.
Some of the anomalies are missed – human error.
Most prenatal systematic scans performs around 17-22nd gestational week, however 20% of the hydronephrotic anomalies appears after the 24th week
UPJO,Ureterocele,Cryptorchidism,Hypospadias,Reflux


Adult UPJ Obstruction
The incidence of pediatric UPJO is well defined, affecting around 60-70% of all antenatally dilated systems.
The incidence of adult UPJ is not known.
Adult UPJ is not a rare finding.

Adult UPJ Obstruction presentation
Flank pain, back pain.
UTI/ Pyelonephritis
Hypertension (rare)
Asymptomatic Incidentally detected during evaluation of other symptoms

Adult UPJ Obstruction management options
Nephrectomy.
Reconstructive surgery:
 Open surgery / Laparoscopic / Robotic
 Endoscopic
  Direct incision
      antegrade/retrograde;
      cold knife/electrocautery/laser
  Acucise balloon dilatation and cutting.

Adult cryptorchidism
factors affecting management
Endocrine function.
Fertility.
Risk of malignancy.

The majority of cryptorchid testes cannot contribute to fertility.
Orchidopexy is not the best treatment for postpubertal cryptorchid patients....

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